Journal of Clinical Pharmacy and Therapeutics, 2015, 40, 486–488
Spontaneous rectus sheath haematoma associated with rivaroxaban treatment A. Tas Tuna* MD, O. Palabiyik† MD and S. G. Beyaz* MD *Department of Anaesthesiology and Reanimation, Sakarya University Faculty of Medicine, Sakarya, and †Department of Anaesthesiology and Reanimation, Sakarya University Training and Research Hospital, Sakarya, Turkey
Received 14 July 2014, Accepted 7 October 2014
hospitalization, hypertension was controlled with carvedilol (Dilatrendâ 25 mg tablet, Roche, Milano, Italy) once daily, valsartan–hydrochlorothiazide (Co-Diovanâ 160/25 mg tablet, Novartis, Istanbul, Turkey) once daily and amlodipine besylate (Norvascâ 10 mg tablet, Pﬁzer, Istanbul, Turkey) once daily. She was discharged and prescribed rivaroxaban (Xareltoâ 10 mg tablet, Bayer, Leverkusen, Germany) once daily for anticoagulation. Two days later, the patient was admitted to the emergency room of our hospital with complaints of dyspnoea, abdominal pain and swelling. She was conscious and cooperative. Auscultation revealed bilateral rough respiratory sounds and a 2/6 systolic murmur on mitral focus. The left sinus was closed on chest radiography, and computed tomography (CT) of the thorax revealed bilateral atelectatic-consolidated areas and a parenchymal ground-glass appearance. Laboratory test results were normal except for the following: white blood cell count of 28500 mm3, Hb of 55 g/dL, Htc of 166%, plasma glucose of 323 mg/dL, urea of 128 mg/dL, creatinine of 35 mg/dL, uric acid of 107 mg/dL, calcium of 77 mg/dL, albumin of 29 g/dL, creatine kinase of 496 U/L, prothrombin time of 157 sn and international normalized ratio of 148. Arterial blood gas analysis was as follows: pH of 746, pO2 of 819 mmHg, pCO2 of 389 mmHg, HCO3 of 279 mmol/L and SpO2 of 976%. A heterogeneous lesion consistent with a haematoma, reaching 55 cm in thickness, was detected in the abdominal rectus muscle on an abdominal CT (Fig. 1). The patient was diagnosed with rivaroxaban-related rectus muscle haematoma and was followed up in the intensive care unit. General surgery clinic did not suggest a surgical intervention, and anticoagulant was discontinued. An erythrocyte suspension and fresh frozen plasma were administered. The patient developed respiratory insufﬁciency and was intubated. Mechanical ventilation support was provided. The patient died on day 15 of hospitalization due to renal dysfunction and sepsis, in addition to the pre-existing pathologies.
WHAT IS KNOWN AND OBJECTIVE
What is known and objective: Anticoagulant therapy is used for the prevention of stroke in patients with atrial ﬁbrillation (AF). Rivaroxaban is one of a new generation of anticoagulant direct factor Xa inhibitors. Its oral use and lack of need for dose monitoring are important features for improving patient comfort. Rivaroxaban may lead to spontaneous haemorrhage, although more rarely than conventional anticoagulant therapy. Case summary: We present the case of a patient with AF who developed a haematoma in the abdominal rectus sheath on day 2 following rivaroxaban use. What is new and conclusion: To the best of our knowledge, such an occurrence has not been described previously in the literature.
Keywords: anticoagulant therapy, rectus sheath haematoma, rivaroxaban
Anticoagulant therapy has been used for the prevention of stroke in atrial ﬁbrillation (AF) and for prophylaxis and treatment of venous thromboembolism for many years. New-generation thrombin inhibitors and factor Xa inhibitors are used for the same purposes, in addition to vitamin K antagonists. The popularity of these new-generation drugs is gradually increasing, as they can be administered perorally.1,2 In addition, they are usually well tolerated by patients and are associated with fewer haemorrhagic complications than traditional anticoagulant therapy.1,2 In this paper, we describe the case of a patient with AF who developed a haematoma in the abdominal rectus sheath following use of rivaroxaban. To the best of our knowledge, a similar occurrence has not been described previously in the literature.
A 75-year-old female patient was admitted to the cardiology clinic of our hospital due to the development of AF with a rapid ventricular response (AFRPR) and uncontrollable hypertension while receiving treatment for pneumonia in another hospital. The patient also had diabetes mellitus and Alzheimer’s disease. Electrocardiography of the patient revealed AFRPR, an ejection fraction of 55%, moderate mitral insufﬁciency, severe tricuspid insufﬁciency and pulmonary hypertension. During one week of
CASE DISCUSSION Atrial ﬁbrillation is a common arrhythmia and a major risk factor for stroke and systemic embolism.3 Although its general prevalence is 55%, this rises to 178% in those older than 85 years.1 AFrelated mortality is 24% within 30 days unless treated.4 Anticoagulant drugs have long been used to prevent thromboembolism, which is responsible for stroke in AF. Due to vitamin K antagonists (warfarin), the best known anticoagulant drugs, interact with many foods and medications, have narrow therapeutic windows and require regular laboratory follow-up, new drugs such as direct thrombin inhibitors and Factor Xa inhibitors have been developed.
€ Correspondence: A. Tas Tuna, Sakarya Universitesi E gitim ve Arasßtırma Hastanesi, Merkez Kamp€ us€ u, Adnan Menderes Caddesi, Sa glık Sokak No:195, Sakarya, Turkey. Tel.: +90 264 444 54 00 11 60; fax: +90 264 275 67 44; e-mail: [email protected]
© 2014 John Wiley & Sons Ltd
A. Tas Tuna et al.
Rectus sheath haematoma associated with rivaroxaban
Fig. 1. The white arrow shows the haematoma in the abdominal rectus sheath.
patient who underwent total hip arthroplasty and in a HIV+ patient who underwent surgery for a right malleolar fracture.10,11 Although patients with haemorrhagic pericarditis, pulmonary haemorrhage and spontaneous splenic rupture have been reported, rectus sheath haematoma associated with rivaroxaban has not been reported.9,10,11–14 Rectus sheath haematoma is a rare but important cause of abdominal pain.15 It is characterized by abrupt severe abdominal pain, immobility of the abdominal wall muscle and a palpable mass.15 Haemorrhage may originate from the epigastric artery and branches or directly from rectus sheath rupture.15,16 Anticoagulant therapy is important in the aetiology of rectus sheath haematoma.17 In the literature, patients who developed rectus sheath haematoma during heparin, warfarin and aspirin use have been reported.6,15,18,19 The diagnosis of rectus sheath haematoma can be made with CT, ultrasonography and magnetic resonance imaging.20 In our case, a haematoma was seen in the rectus sheath on a CT that was obtained for abdominal pain of abrupt onset and abdominal swelling beginning two days after taking rivaroxaban given for prevention of AF-related thromboembolism. The haematoma was likely related to the use of rivaroxaban. Most rectus sheath haematomas are typically self-limited, with the bleeding stopping, and the treatment is usually conservative.17,20 In haemodynamically unstable patients, anticoagulant therapy may be discontinued. An antidote may be administered if available, followed by aggressive ﬂuid resuscitation and blood and blood product transfusion if necessary.15,16,18 With bleeding resistant to conservative treatment and the application of an antidote, angiography and percutaneous arterial embolization or surgical ligation of epigastric vessels may be attempted.20 We administered an erythrocyte suspension and fresh frozen plasma and did not consider surgical treatment as the haematoma had not increased in size. Although the bleeding stopped, the patient died due to non-haemorrhagic causes, including existing comorbidities, renal and respiratory insufﬁciency, and sepsis development.
Rivaroxaban is a new-generation oral anticoagulant, which acts by selectively blocking the active component of factor Xa.2 It prevents both intrinsic and extrinsic pathway-mediated thrombin formation.6 It is rapidly absorbed in the gastrointestinal tract after oral ingestion, and it reaches maximum factor Xa inhibition activity in 2–4 h.7 Sixty per cent of the drug is metabolized in the liver and 40% is eliminated in urine, with minimal amounts in faeces.8 The half-life of the drug is between 5 and 9 h in healthy volunteers, but it is about 11–13 h in the elderly.2,3 Rivaroxaban has a number of advantages. These include a peroral administration route, not interacting with many drugs and foods, being well tolerated, not requiring continuous dose monitoring and resulting in fewer haemorrhagic complications.1–3 However, a disadvantage is the absence of a speciﬁc antidote for rivaroxaban.1–3 In the literature, the development of a spinal epidural haematoma was reported two days after the administration of rivaroxaban for the prevention of venous thromboembolism following proximal tibia surgery.9 In addition, gastrointestinal haemorrhage was reported after rivaroxaban administration in one
WHAT IS NEW AND CONCLUSION
Rivaroxaban may lead to spontaneous rectus sheath haematoma, despite it being reported to cause fewer haemorrhagic complications than traditional anticoagulant drugs. CONFLICT OF INTEREST None.
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